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The number of stapler firings for rectal transection has been suggested as a modifiable risk factor, but its independent role and optimal threshold remain unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate the impact of the number of stapler firings on anastomotic leakage after rectal surgery and to assess the influence of surgical and patient-related variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources<\/jats:title>\n                    <jats:p>A comprehensive search of PubMed, Cochrane Library, and Ovid MEDLINE was performed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Selection<\/jats:title>\n                    <jats:p>Studies reporting anastomotic leakage rates stratified by stapler firing count (one, two, or three or more) were included.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Intervention(s)<\/jats:title>\n                    <jats:p>Rectal transection with one or more stapler firings during minimally invasive anterior resection for rectal cancer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main Outcome Measures<\/jats:title>\n                    <jats:p>Incidence of anastomotic leakage according to stapler firing (SF) count.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Twenty two studies including 8,725 patients and 784 anastomotic leakage events were analyzed. A single stapler firing was associated with a significantly reduced risk of anastomotic leakage compared with two stapler firings (odds ratio 0.57, 95% confidence interval 0.39\u20130.83), three or more stapler firings (odds ratio 0.28, 95% confidence interval 0.16\u20130.51), and two or more stapler firings (odds ratio 0.46, 95% confidence interval 0.34\u20130.63). The risk of anastomotic leakage was lower with fewer than three stapler firings compared with three or more stapler firings (odds ratio 0.38, 95% confidence interval 0.30\u20130.48). Meta-regression identified low rectal transection and preoperative radiotherapy as significant effect modifiers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Limitations<\/jats:title>\n                    <jats:p>All included studies were observational, introducing potential bias and increased heterogeneity and the certainty of evidence was low across all comparisons.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Three or more stapler firings were consistently associated with a higher risk of anastomotic leakage. However, because the certainty of evidence was low and owing to exploratory meta-regression findings, stapler firing number appears to reflect operative complexity more than a definitively established independent causal risk factor.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s10151-026-03364-y","type":"journal-article","created":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T11:05:21Z","timestamp":1779793521000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The impact of the number of stapler firings on anastomotic leakage in minimally invasive rectal surgery: risk factor or technical marker of complexity? 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